Sample 2015- 2016 Influenza Vaccine Consent And Screening Form printable pdf download

SAMPLE 2015- 2016 INFLUENZA VACCINE CONSENT AND SCREENING FORM

Injectable (Flu Shot) or Nasal Spray Flu Vaccine

Section 1: Information about the student to receive vaccine (please print):

Name: (Last, First, MI)

Date of birth:

Age

Sex: (Circle)

_____

____ _____

Male

Female

Month

Day

Year

Street Address:

Student grade:

City:

State:

Zip:

Phone:

(

)

Section 2: Consent for Vaccination

CONSENT FOR CHILD’S VACCINATION: I have read or had explained to me the 2015-2016 Vaccine Information

Statement for the influenza vaccine and understand the risks and benefits.

I GIVE CONSENT for my child named at the top of this form to get

I DO NOT GIVE CONSENT for my child named at

vaccinated with this vaccine. Children younger than 9 years of age may

the top of this form to get vaccinated with this

need 2 doses of vaccine. (If this consent is not signed, dated and

vaccine.

returned, my child will not be vaccinated.)

_________________________

____/____/____

_________________________

____/____/____

Signature of Parent/Legal Guardian

Date

Signature of Parent/Legal Guardian

Date

Section 3: Permission to Share Information:

Complete only if you consented to have your child receive flu vaccine.

This information will be shared to ensure that your child is appropriately vaccinated. You may refuse to sign this authorization

to share information. Refusal to sign will not affect your child’s ability to obtain vaccine

I, ____________________________________, give permission to the individual and/or entity that administered the 2015 -

(Print your name)

2016 influenza vaccine to my child _____________________________________ to share copies of the 2015 – 2016 flu

(Print child’s full name)

vaccine consent form and vaccination record with my child’s school and health care provider named below, as well as with

the Massachusetts Department of Public Health and the local board of health in my community. I also give permission for

each of these entities to share the 2015-2016 seasonal influenza consent form and vaccination record with each other.

My child’s health care provider:

My child’s school:

Name:___________________________________

Address: ________________________________

City or town: ______________________________

_________________________________

•

This health information is disclosed at my request and to ensure my child is appropriately vaccinated.

•

This permission expires at the end of the 2015 – 2016 school year.

•

If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy

regulations, the information received may no longer be protected by federal privacy regulations. State privacy

regulations cover information received by the MA Department of Public Health and local boards of health.

•

I understand that I may inspect or copy the protected health information to be disclosed under this permission to share.

•

Finally, I understand that I may withdraw this permission in writing at any time by sending written notification to:

________________________________________________________________________________

(School/institution/individuals handling withdrawals must insert name and address)

However, if I withdraw permission at a later date, any vaccine consent form and vaccine record already shared will not be

covered by the withdrawal.

____________________________________________

___________________________________

Signature of

Parent or Guardian

Printed name of Parent or Guardian

Address:______________________________________________________

Date signed:____/____/____

Permission to share is compliant with HIPAA and FERPA requirements.

Flu consent Combined 2015-2016_ 8-15

Sample 2015- 2016 Influenza Vaccine Consent And Screening Form

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